Nurse Practitioner Restrictions

This article discusses limitations on Nurse Practitioner's scope of practice. Unfortunately, Nurse Practitioners in some states are unable to practice completely what they went to school for. Some examples and explanations are provided in this article.

I decided to become an ARNP because I knew it would be an empowering career. Although the work of an ARNP and Physician is similar, there are many differences. Physicians tend to use a scientific approach when addressing their patients, due to their rigorous science-based education. ARNPs approach the patient holistically. When I diagnose a patient with Diabetes Mellitus Type 2, I explain what this disorder is and the causes; I explain the treatment plan; I discuss nutrition and physical activity changes; I assess the patients comfort level with their treatment; I encourage the patient to discuss their feelings upon finding out they have this new chronic disorder; and I reassess the patient within a 2-4 week timeline. I am interested in making sure the patient understands their disorder and how they can manage it.

Unfortunately, in Florida there are some limitations on the ARNP that allows physicians to have more power. For example, Physicians can order home health treatment,controlled substances, and open their own practices without having a supervisory protocol. It is frustrating that Florida is one of the few states that has such strong limitations on ARNP scope of practice. For example, ARNPs cannot order durable medical equipment for Medicare patients in Florida. This means I cannot order a low back brace for my patient with chronic low back pain; I cannot order diabetic shoes for my patient with DM Type 2; I cannot order a cane for my patient with Parkinson’s.

Moreover, ARNPs cannot prescribe controlled substances, including benzodiazepines that so many of my patients take for their anxiety or insomnia. Currently, I write out the prescription and my supervisory physician will sign the prescription. The only people suffering are my patients because this delays access to their medications. Recently,Tramadol was added to the controlled substance list. I had previously prescribed this medication frequently for my patients with chronic low backpain and severe osteoarthritis. I was not thrilled the day I received a phone call from the pharmacist telling me that tramadol was effectively now a controlled substance.

In addition, ARNPs cannot order home health treatment. This does not make sense to me since I am the primary care provider for many patients and oversee their medical care. So if I have a patient with history of a stroke and hemiparesis, I believe I should be able to order home health physical therapy for them. If I have a patient with dementia and uncontrolled hypertension, I believe I should be able to order home health blood pressuremonitoring for them.

Lastly, I do not like that ARNPs have to have a protocol with a supervising physician. It’s as if the physician defines our scope of practice and not the state board of nursing. If I wanted to open up my own practice, I would need a physician to be the medical director. This means I would have to waste a few thousand dollars a month just to pay the physician for having their name on the wall of my clinic. I would be seeing the patients, overseeing the clinic, and reviewing charts, but would still have to pay my supervising physician to do nothing except ‘supervise me’.

I am hoping with the Affordable Care Act and the abundance of new people seeking primary health care, that Florida will increase the scope of ARNPs. Working with the ANA, FNA, and other nursing organizations, I plan to fight for these rights. I see myself having my own practice where I see a variety of illnesses and ages. I hope that the care provided will not be based as much on cost as it is today. We already know ARNPs will be a forefront to help with the primary care shortage.

Florida is my home too and its so frustrating to feel like theres no way to advance my career there -ARNPs have so many limitations, and clinical nurse specialists aren't even considered an advanced practice...

Aug 21, '15

Great article, thanks for sharing Amazing that it's so different from state to state. And frustrating.

Aug 21, '15

Texas is also a 'restrictive' state, indeed frustrating. Thank you for the great article.

Aug 21, '15

I thought that Texas was not a very restrictive state. All the research that I have done has led me to believe that the NPs in Texas do not need the supervising physician. Or if they do, that they physician only has to look at like 10 percent of the NPs cases. Im not sure which one it is.

Aug 21, '15

Thanks everyone! I think the best we can do is be involved in the ANA to increase nursing advocacy. Hopefully in the future, states will have more congruent practice laws.

Aug 21, '15

The northwest has no restrictions so this concept of supervised or controlled practice is foreign to me.

Aug 21, '15

I joined AN just so I could comment on this topic, NP need to do as MDs do and lobby. To me it seems like it is all about money it can't be about patients. I remember here in Florida when the MDs made a big deal about the DNP degree and cried about nurses having the title Doctor in front of their name. I think the ANA and other nurse associations should be going to state and local representatives and explaining to them how this affects patient care, it isn't right that you do most if not all the work and you need a MD to over see your work, and it affects the level of care you are able to provide we all need to get together and fight this.

Aug 21, '15

NP's in Texas are required to have a collaborating physician and a prescriptive authority to then be able to prescribe DMEs, dangerous drugs (formulary) and controlled substances Schedules 3-5. We are "given the authority" to do so by said collaborator delegating these tasks within a prescriptive authority agreement. We can only prescribe what is "authorized" within that agreement. Not really autonomous practice.

I was under the impression that the restriction came in 2012 according to this rule, and was applicable to all medicare reimbursement:

In a November 16, 2012 final rule titled “Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, DME Face-to-Face Encounters, Elimination of the Requirement for Termination of Non-Random Prepayment Complex Medical Review and Other Revisions to Part B for CY 2013” we established a face-to-face encounter requirement and new requirements for written orders prior to delivery for certain items of DME (77 Federal Register 68892). These requirements may be found in the Code of Federal Regulations at 42 CFR § 410.38(g).
The law requires that a physician must document that a physician, nurse practitioner, physician assistant or clinical nurse specialist has had a face-to-face encounter with the patient. The encounter must occur within the 6 months before the order is written for the DME..

However, on April 16, 2015 this law became effective:

n April 16, President Obama signed into to law H.R. 2, the Medicare Access and CHIP Reauthorization Act of 2015. The law replaces the flawed Medicare Sustainable Growth Rate (SGR) formula for provider reimbursement with an improved payment system that rewards quality, efficiency, and innovation. Include nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists in the new Merit-Based Incentive Payment System. Lastly, it removes the barrier to practice in Medicare, allowing APRNs to order durable medical equipment and document the required face to face encounter.

I know I have ordered DME in Florida, and I don't know if the supplier isn't doing due dilligence, or my note is good enough. I've been told it just has to include DME requested and detailed description of need with diagnosis.

Aug 21, '15

Yes this article was written prior to that. Luckily since then, the federal government mandated that APRNs can order DME. Prior to that all orders were rejected and suppliers were writing APRNs rude letters about reporting them to medicare. I think this shows how healthcare is changing, although slowly, for the best.

Aug 21, '15

Nursing lobbies for things, and they're quite successful. However, very little is done to champion advanced practice. I've heard so many nurses say "I'm just a nurse." I've heard NPs say "I'm just a nurse practitioner." What the heck? I never invested much in, or cared little about, being a nurse. It was merely a stepping stone. Having said that, NPs need to rise, go to their boards of nursing, demand that LPN and RN appointees regulate us, push the collaboration and supervision back down the throat of medical lobbyists, obtain full prescriptive authority for all meds and all devices, require consistent, uniform education, and accelerate. I think too many NPs become content with having a new job, doing that extra little bit of "care" they couldn't do as a nurse, and then move on with life. Everyone gets the ego squash when we're somehow usurped by a physician. I have not and will not ever suggest that we're equally trained or capable, yet I surely will not suggest we are incapable or somehow less. Rather, we need to define ourselves, make our own mission statement, set some objectives, and then move on with being solid, fully competent clinicians.

The OP's article stung when she admitted to not knowing tramadol had become a controlled substance. Are you under a rock?! How do you expect to advance yourself and your profession like that? We have all got to know our boundaries and start working aggressively (aggressively) to expand them. It is a ding for everyone when you learn you can't prescribe something. I had someone come to me the other day stating "Dr. SuchandSuch told me he wants you to prescribe me Saphris." My reply was, "If he wants you to take it why didn't he prescribe it?" Who is this schmuck to send a mutual patient back telling me what to prescribe? If he wants to treat SMI he needs to treat it.

Aug 21, '15

Tramadol did not become a controlled substance until last year. And as a Florida NP we cannot prescribe controlled substances.

Another thing is that advanced practice nurses should always support each other instead of bringing each other down.